0342 (SATT)PERMIT APPLICA ION' _6 t1
City o1 La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from date of issuance: OR, if work, has been suspended or abandoned for a p :riod of 180 days
APPLICANT �• t (L, F. omt v e
Lr TVrrI
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSAT ON INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION:'I hereby affirm that I am licensed. under provisions of Chapter 9 .
the permit is for one hundred ($100) o, less. I certify that it the performance of the work for which this permit is
(commencing with Section 7000) of•Division 3o1 the Business and Professions Code, and my license is in full force
issued. I shall not employany person in anymannerso asto Become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant- .
Date — Contractor
NOTICE TO APPLICANT: If, after making this Certificate of I xemption, you should become subject to the Workers' ..,
OWNER -BUILDER DECLARATION:' I hereby affirm Miff am exempt from the Contractor's License Law for.the .
Compensation provisions of the Labor Code, you must fort with comply with such provisions or this permit shall 'u
be deemed revoked.
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
`x.49
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION,
such permit tofile.asigned statement that heislicensed pursuant tothe provisions ofthe Contractor's License Law ..
0 hereby certify that no excavation five (5) or mofe feet in.lepth into which a person is required to descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt •
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or '
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit:,
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 89. -
subjects the applicant to a civil penalty of -not more than five hundred dollars ($500.):
`C.A.C.)
❑ I, as owner o1 the property, or my employees with wages as their sole compensation, will do the work, and the
0 As owner -builder, I will not employ anyone to do work which would require•a permit from the Division of
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
ADDRESS
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
;, • ,O Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden ofproving that
Date Applicant
he did not build or improve for the purpose of sale.).
'CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
� O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
of the work for which this permit is -issued (Sec. 3097, Ci -r. C.).
7044, Business and Professions Code: The Contractor's License Law does not apply,to an owner of property who
Lender's Name
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
SSB
Contractor's License Law.).
Lender's Address
" ❑ I am exempt under -Sec. B. & P.C. (Attached Certificate).
I certify that I have read this application and slate that thaabove information is correct. I agree to comply with,all . .
Date Owner
city and county ordinances and state laws relating to building construction, and hereby authorize•representatives -
'
of this county to enter upon the above=mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: 1 -hereby affirm. that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance-, or a certified.copy thereof (Sec. 3800. Lab. C.).
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF EhiRY: l certify I have read this application and state that
o Certified copy is hereby furnished. r
the information given is correct. I agree to comply with a 1 state laws and county ordinances relating to buidling
' O Certified copy is filed with the Cily'Building Inspection Department or City Department.
construction, and authorize a'representative of the City .1 La Ouinta Department of Building and Safety to enter
Date l ? r ( applicant f yC,____:
upon the property for which I have applied for this permit for the purpose of making inspections.
APPLICANT �• t (L, F. omt v e
Lr TVrrI
ADDRESS _
P,
P, 0, Bax 780
CTI�V/COM, MUNITVta,
E CA 92253.
i,30.;;016=i
Li�.a.i.i.C�.
JOB SITEAOORACE
Pbsa ita
CITY/COMMUNITY/STATE/ZIPLL a,�t�T 922
{•Ll
BOK
PAG
PRC
C
Constructitin Fee 373,00
TWIN
RNG
SE.,
S
X4`496-1
`x.49
P-2
SB .
TRACT NAME -
Santa Rosa emm
OWNER NAME L. F. MI)
CON., T,HACTOR-Fnden a NAME a
tim
ADDESS
Pe R 0, B= 780
C_. a COMM__ 11NITV/ST`TEC 92253
X15566+r4`-t131f`5,�LT'
Sya_�f
`3,33,762
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC ♦
-
USE OF PERMIT
^e Family WeWellingdal. �'
ZON
FSB
SSB
SSB
RSB
OFC
- ZONE ORD
LOT SZEND
SIDE'
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPUPRMT n.1 4.7.
Permit to C)onstny-t Model P -2-B
Dl.li 11390 Sq..
�Ft.
Porch � � 112 Sq, L'yto
Garage 422 Sq. Ft.
Mechanical. Fee $ 31.00
Plait Check Fee 242.45
Constructitin Fee 373,00
Electrical Fee 31,25
SMI Fee 5,57
Pluffbig Fee 48,50
Property DweloPment Fee 300,00
TOTAL
FEE
$ 1,.031.77
• VALUATION $ 79,103.2n
BLDG P41 �,
I0
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set'Back
33
Ventilation System
2
Ftgs & Frms
7-
34
Plenums & Ducts
2A
'Slab Grade
A"
35
Furnace Compart.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire -Wall
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final-,
10A
fireplace T.O..
❑
OP'N
NO.
ADDITIONAL INFORMATION
,
-7110"" y 9:0 0
-
C p, d1 �
0\-\ CNP_,�,n n Syj
1
`
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath � p2
12 Internal Lath
1.2A , Drywall
13 Finish Grade
INSULATION Thick R"
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb 'r n
16 Water Piping
17 Rough Plumb `
18 Vents
19 Sewage Disposal
20 Sewer 7.
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test S l6
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P/(
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final